In this month's Archives, Jambusaria-Pahlajani et al1 document that there is clinical equipoise among published consensus panel guidelines regarding the management of high-risk and, specifically, perineural cutaneous squamous cell carcinomas (cSCCs). They then show that there is similar equipoise among individual Mohs surgery practitioners as well.
Why does this uncertainty exist? The reason, in a nutshell, is that there is a paucity of high-level data on which to base therapeutic decisions. A recent Cochrane systematic review of randomized controlled trials addressing the issue of interventions for nonmetastatic SCCs of the skin found only 1 randomized controlled trial and 1 ongoing trial in the literature.2 The authors concluded that, in view of the absence of evidence from prospective randomized studies, current guidelines on the management of primary SCCs of the skin are largely based on case series.2 Why is there a paucity of well-designed and executed studies? Several factors probably contribute. First, in addition to being relatively uncommon, the entities being studied (eg, high-risk cSCCs and perineural invasion [PNI]) and their risks are not well defined; second, once they are defined, it is not clear what level of risk warrants additional diagnostic or therapeutic options; and third, there are multiple diagnostic and therapeutic options.
Miller SJ. Defining, Treating, and Studying Very High-Risk Cutaneous Squamous Cell Carcinomas. Arch Dermatol. 2010;146(11):1292-1295. doi:10.1001/archdermatol.2010.309